Depressive Disorder Flashcards
What is the defintion of Depressive Disorder?
An affective mood disorder characterised by persistent low mood, loss of pleasure, and/or lack of energy accompanied by emotional, cognitive and biological symptoms
What is the aetiology of Depressive Disorder?
- Genetics: more common in women, family history of depression, 40-50% monozygotic concordance.
- Psychosocial factors such as personality type, stressful life events and failure of effective stress control mechanisms
- Monoamine hypothesis: deficiency in noradrenaline, serotonin and dopamine
What are Core Symptoms of Depressive Disorder?
- Anhedonia: lack of interest in thing which were previously enjoyable to the patient
- Low Mood: present for at least 2 weeks
- Lack of Energy
What are other symptoms of Depressive Disorder?
Cognitive Symptoms
- Lack of concentration
- Negative thoughts
- Excessive guilt: feelings of worthlessness or excessive or inappropriate guilt, nearly every day
- Suicidal ideation
Biological Symptoms
- Diurnal variation in mood: more pronounced low mood at specific times of the day usually morning
- Early morning wakening
- Loss of libido
- Psychomotor retardation
- Weight loss and loss of appetitie
Psychotic Symptoms
- Hallucinations and delusion
How is Depressive Disorder screened?
- ‘During the last month, have you often been bothered by feeling down, depressed or hopeless?’
- ‘During the last month, have you often been bothered by having little interest or pleasure in doing things?’
‘yes’ answer to either of the above should prompt a more in-depth assessment.
What is the ICD-10 classification of Depressive Disorder?
- Mild depression = 2 core symptoms + 2 other symptoms
- Moderate depression = 2 core symptoms + 3–4 other symptoms
- Severe depression = 3 core symptoms + ≥4 other symptoms
- Severe depression with psychosis = 3 core symptoms + ≥4 other symptoms + psychosis
What are investigations for Depressive disorder?
- Diagnostic questionnaires (PHQ-9, HAD)
- Blood tests: FBC, TFTs, U&Es, LFTs, Calcium, Glucose
- Imaging: MRI or CT scan may be required if atypical presentation
How is subthreshold depressive symptoms or mild depression managed?
- Watchful waiting: should be considered and reassess patient again in 2 weeks
- General measures
- Sleep hygiene
- Active monitoring for people who do want an intervention
- Psychosocial interventions (Computerised CBT, Individual guided self-help based on CBT principles, Structured group physical activity programme, Group-based CBT)
When should subthreshold depressive symptoms or mild depression be treated with medicaiton?
Do not use antidepressants as first line therapy but consider them for people with:
- Past history of moderate or severe depression
- Initial presentation of subthreshold depressive symptoms that have been present for a long period (typically at least 2 years)
- Failure of other interventions
- If a patient has a chronic physical health problem and mild depression complicates the care of the physical health problem
What is the management of unresponsive, moderate and severe depression?
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Start an antidepressant (normally a selective serotonin reuptake inhibitor, SSRI). Examples are Sertraline, Paroxetine. Continue use for 6 months after first episode, 2 years after second episode
- SNRI (duloxetine, venlafaxine), TCA (clomipramine, amitriptyline) and MAOIs can be used if SSRIs are ineffective
- Lithium and antipsychotics may be used as adjuvants. Agomelatine.
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‘High-intensity psychological interventions’: Individual CBT, Interpersonal therapy (IPT), Behavioural activation, Behavioural couples therapy. For people who decline the options above, consider:
- Group-based CBT or individual CBT for patients with chronic physical health problems
- Short-term psychodynamic psychotherapy for people with mild to moderate depression
- Counselling for people with persistent subthreshold depressive symptoms or mild to moderate depression
- Suicide risk assessment performed on all. Psychiatry referral if suicide risk is high, depression is severe, recurrent depression or unresponsive to initial treatment.
- Mental health act may need implementing
- Social support may be needed
When is ECT indicated in depressive disorder?
ECT may be indicated for
- Acute treatment of life-threatening depression
- Rapid response required
- Depression with psychotic features
- Severe psychomotor retardation or stupid
- Failure of other treatments
How does depression present differently to dementia?
Depression present with
- Short history, rapid onset
- Biological symptoms e.g., weight loss, sleep disturbance
- Patient worried about poor memory
- Reluctant to take tests, disappointed with results
- Mini-mental test score: variable
- Global memory loss (dementia characteristically causes recent memory loss)
What is the defintion of Bipolar Disorder?
Bipolar disorder is a chronic episodic mental health disorder characterised by periods of mania/hypomania alongside episodes of depression.
What is the pathophysiology/aetiology of Bipolar Disorder?
- Monoamine hypothesis: increased central monoamines
- Dysfunction of HPA axis and dysfunction of HPT axis (increased)
- Stressful or significant life events may precipitate onset of 1st manic episode
- Heritability shown in monozygotic twin studies (40-70% concordance). Lifetime risk of development
What is the ICD-10 for Bipolar Disorder?
Bipolar affective disorder requires at least 2 episodes in which person’s mood and activity levels are significantly disturbed – one of which must be mania or hypomania
- Mania requires 3/9 symptoms to be present from: (1) Grandiosity/inflated self-esteem; (2) Decreased sleep; (3) Pressure of speech; (4) Flight of ideas; (5) Distractibility; (6) Psychomotor agitation (restlessness); (7) Reckless behaviour, e.g. spending sprees, reckless driving; (8) Loss of social inhibitions (leading to inappropriate behaviour); (9) Marked sexual energy.
- Division of bipolar disorder into 5 state: (1) Currently Hypomanic (2) Currently manic; (3) Currently depressed; (4) Mixed disorder; (5) In remission.
